Deadline approaches for health care

Sunday

Jun 24, 2007 at 12:01 AMJun 24, 2007 at 1:32 AM

As of July 1, all Massachusetts adults are required to have health insurance, with the state offering insurance options to residents whose employers do not offer coverage. The landmark first-in-the-nation effort, signed into law a year ago, is designed to increase access to medical care. Subsidies have been established for residents who earn beneath 300 percent of the federal poverty level and a new public agency, the Commonwealth Health Insurance Connector, has been marketing insurance plans.

By Jennifer Lord, DAILY NEWS STAFF

Nathan Prouty had only been without health insurance for two weeks when he discovered how desperately he needed it.

Prouty was taking time off after his college graduation, heading overseas for a visit to Prague, when his mouth started hurting. The slight throb developed into a searing pain as he debated whether the infected wisdom tooth was important enough for a doctor's visit.

"I finally had to go to the emergency room for some antibiotics and Valium," said Prouty, a Waltham resident. "I still have a collection agency chasing me for the bill. Hopefully, I won't ever have to go through that again."

The 23-year-old artist recently became one of thousands of uninsured Massachusetts residents who obtained health care coverage through Commonwealth Care, the state's subsidized insurance program. As of July 1, all Massachusetts adults are required to have health insurance, with the state offering insurance options to residents whose employers do not offer coverage.

The landmark first-in-the-nation effort, signed into law a year ago, is designed to increase access to medical care. Subsidies have been established for residents who earn beneath 300 percent of the federal poverty level and a new public agency, the Commonwealth Health Insurance Connector, has been marketing insurance plans.

About 95 percent of the state's population was insured before the legislation, with most receiving their insurance through their employer, according to Jon Kingsdale, executive director of the Health Connector. About a third of the 327,700 uninsured adults in the state are now enrolled.

"Those are real people, many of whom have gone without medical care because they didn't have insurance," Kingsdale said. "People are responding to our outreach efforts and clearly recognizing that they are better protected when they have health insurance."

Enrollment in Commonwealth Care spiked to more than 79,000 as of June 1, an increase of 10,000 over the previous month. Commonwealth Care is available to residents who earn beneath 300 percent of the federal poverty level - $30,630 for an individual, $61,950 for a family of four - who don't qualify for Medicare, Medicaid or have insurance through their employer.

"They're unemployed or working a couple of part-time jobs," Kingsdale said. "They tend to be somewhat young, more males than females - the so-called 'young invincibles' who don't believe they'll ever get sick."

Prouty admits that he falls squarely into this category. Growing up, he was always covered by his parents' health insurance and as he planned for life after college, he figured he was young and healthy enough to get by without insurance for a few years.

"Among me and my friends in college, health insurance was always something that was taken care of by someone else," Prouty said. "It was never something I had to think of. To suddenly leave school and just get slammed with (a health problem) you didn't expect - that was definitely a shock."

The jobs Prouty has worked since college have not offered insurance. He went uncovered during a nine-month stint as a ceramics artist-in-residence at a Maine arts center and he doesn't qualify for insurance at his current job at the LaCoste Gallery in Concord.

When he heard about the state mandate, he called the help line at the consumer organization Health Care for All and discovered he qualified for assistance.

"I'm much more comfortable with having insurance," Prouty said. "I had to wait to get eye glasses and I haven't gone to the dentist in years. I just want to know that I'm healthy and stay healthy."

Lindsay Tucker, health reform coalition coordinator for Health Care for All, said callers to its hotline fall into two categories: people who are thrilled to have access to health insurance and those who feel the state shouldn't be forcing the additional expense on their otherwise-healthy shoulders.

"It might be that a lot of folks aren't familiar with the terminology, they don't know what a premium is, what a co-pay is. A lot of folks didn't grow up with insurance," Tucker said. "A lot of people feel relatively healthy and don't want to put money in something, quote unquote, 'unnecessary' like health insurance."

Tucker believes people will gradually come around to the benefits of preventative care and noted that better access to health services may help with prevalent health issues such as obesity.

"What we're seeing a lot is somewhat gendered," Tucker added. "A lot of women out there are talking about the benefits, they understand preventative care. The men, on the other hand, don't believe they need health insurance, they say if they break a leg, they'll just pay the hospital bill."

The Commonwealth Care plan is offered on a sliding scale. Those at the federal poverty level - $10,212 for an individual, $20,652 for a family of four - pay nothing. Monthly costs slide upward, reaching a $106 monthly maximum premium for a person making $30,636 or $105 per adult in a family of four making $61,956.

For those who do not qualify for Commonwealth Care, there is Commonwealth Choice, insurance plans offered by Fallon Community Health Plan, Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, Neighborhood Health Plan and Tufts Health Plan. Costs for the plans vary with age and location, with young people, who have fewer health costs, receiving lower rates.

A 40-year-old in Framingham, for example, would pay $144 a month for the lowest cost no-prescription plan, which is offered by Fallon. Adding prescription coverage, a requirement by 2009, brings the cost up to $170. The highest plan offered comes from Harvard Pilgrim - $544.36 a month brings a $10 doctor co-pay and a $10-$45 out-of-pocket prescription cost.

According to the state, a comparable plan without prescription drug coverage and a $5,000 deductible currently offered to the average uninsured person through the non-group market in the eastern region costs $335 per month.

For a family of four, the lowest Commonwealth Choice price, again offered by Fallon, is $516 without prescription coverage, $608 with prescriptions. The highest priced plan from Blue Cross is $1,470.81.

Companies that employ 11 or more full-time employees are also required to offer a Section 125 Plan that meets Health Connector regulations. Section 125 plans let employees save money through pre-tax payments for health coverage and will pay the so-called "free rider" surcharge if employees or their dependents get medical care that is paid for by the state's Free Care Pool for the uninsured. The companies offer reasonable health insurance plans or pay a Fair Share Contribution of up to $295 per employee.

Employers that do not comply may be charged for any use of free care by an employee or dependent. Employees that do not opt for a plan offered by their employer are not eligible for the state's health plans.

Small businesses in MetroWest have been closely watching the reform efforts and a recent seminar explaining Section 125 Plans was well-filled, said Ted Welte, president of the MetroWest Chamber of Commerce.

"There's been some confusion about which employees are eligible for insurance and a lot of questions about plans offered by the Connector," Welte said.

Dedham resident Karen Power, 49, lost her health insurance when she was laid off from her last job and could not afford to maintain it under COBRA. She recently opened Dandelions, a florist shop in Roslindale, and worried health insurance would remain unaffordable while her business was still in its infancy.

"Being a small-business owner and trying to live the American dream as they say - small-business owners can't afford health insurance," Power said. "I also can't afford to get sick."

Power qualified for Commonwealth Care and said the insurance arrived just in time. About a month and half ago, she came down with strep throat.

"It worked out absolutely fantastic for me. They were so helpful," Power said. "And my antibiotics cost only $1. How great is that?"

The state has set July 1 as the deadline for residents to get insurance, although penalties do not kick in until Dec. 31. Those uninsured by that date will lose their personal income tax exemption for 2007, approximately $219. In 2008, the penalty increases to half the cost of the lowest-priced Health Connector-certified plan for each month without coverage.

There is an appeal process for people who believe they genuinely cannot afford insurance, Kingsdale said. After Dec. 31, residents can also be without insurance for 63 days without incurring a penalty.

"We're trying to make this, the introduction of reform, all about helping people, not hurting people," Kingsdale said.

The challenge, Tucker said, is making the public aware of the options available. Health Care For All has been reaching out to underserved populations, including immigrants, to tell them about the advantages of signing on for health care.

"A lot of these people haven't been eligible for health programs before," Tucker said. "We've been doing a lot of outreach to these communities to let them know what's available to them.

"If it takes people a couple of months to find a plan that works for them, they have time - they really have until Dec. 31 to make a decision," she added. "In the wisdom of the legislature, that's why they made the six month gap."

Illegal immigrants are not eligible for any of the Health Connector programs, Kingsdale said.

"The free-care pool is not going away," Kingsdale said. "It's really hard to know at this point in health reform what the impact is - if it's successful, it will go quite low."